INVOLUTIONAL MELANCHOLIA

BY JOSEPtI BARNETT, l~I. D., AR'TTIUR LEFFORD, M. A., AND DONALD PUSttMAN, tVL D.

Since the first description of involutional melancholia by Kraep- elin, the subject has continued to be in controversy. The descrip- tion of this syndrome has been expanded and differentiated by nu- merous writers; its etiology attributed to a variety of factors and its psychopathology variously conjectured. The diversity of atti- tudes which prevail toward it is eloquently illustrated by a review of the literature.

In this paper, an attempt will be made to clarify and systematize the psychodynamics of the syndrome of involutional melancholia. The psychodynamics of depression, per se, have been described and elaborated by Freud, 1 Abraham, 2 and other psychoanalytic writers2. ' Some of these writers have discussed and analyzed the dynamics of certain aspects of the involutional depression. Yet because of the heterogeneity of the group referred to clinically as the "involutional psychoses," dynamic understanding of this syn- drome has remained obscure. The present discussion will be re- stricted to a discussion of the typical a2dtated depressions of this group. The pre-psychotic personality and precipitating factors will be related to the onset and symptomatology of the syndrome.

The classical psychoanalytic approach to depression has empha- sized several important predisposing factors, namely: the pres- ence of a strong oral dependent fixation in personality develop- ment, the loss of an external object, and the presence of a rigid and severe super-ego. The psychodynamics of depression are ex- plained as due to a basically ambivalent relationship toward ob- jects which "supply narcissistic gratifications to the individual. With the threat of loss, or actual loss, of the object, the hostility of the ambivalent relationship is mobilized and directed against the object. However, since the object is no longer externally pres-

ent , the hostility is directed against the introjected or incorpor- ated representative of the object, this becoming one source of hos- tility directed against the self. Furthermore, the very expression of hostility in a personality with a severe and punitive super-ego results in considerable guilt, which in turn becomes another source of hostility directed against the self.

JOSEPH BARNETTt ARTHUR, LEFFORD AND DONALD PUSIIMAN 655

TI~E I~ PERSONALITY IN AGITATED DEPRESSIONS Although analytic theory emphasizes the oral fixation of patients

who are .predisposed to depression, the writers were impressed by the large number of involutional melancholiacs who showed anal . character traits on clinical examination and whose pre-psychotic personality was predominately anal. Prompted by this impres- sion, the literature was reviewed. It was found that a number of references in the psychoanalytic literature indicate the findings of anal personality traits in depression. Abraham s first noted the obsessive-compul,sive character formation in the free intervals of lnanic-depressive patients. Jelliffe and White 5 noted anal obses- sive tendencies in involutional melancholiacs. Gero / in an analysis of an obsessional neurotic, found that with the breakdown of the character defense the patient suffered a strong but temporary mel- ancholic phase. Fenichel 4 states that involutional melancholia oc- curs in compulsive characters of an especially rigid nature.

Non-analytic authors have also stressed the importance of traits described as anal compulsive by the psychoanalysts. Brew 6 clearly indicated the rigidity and narrowness of adjustment of the pre- psychotic personality of these patients. Titley, 7 in a critical study, concluded that the general type of personality found to antedate involutional melancholia has been recognized by the analytic writ- ers as the anal erotic personality. In another p a p e r / h e describes a similar pre-psychotic personality in those patients classified as agitated depressions other than the involutional depressions. Pal- mer and She rman / in a broad and well-integrated study, stressed the anal pre-psychotic personality and attempted to relate it to the precipitating factors.

It would appear that the existence of anal character traits in the pre-psychotie personality of the involutional syndrome is a fact supported by the clinical findings of psychiatrists differing widely in theoretical orientation. It is felt therefore, that a more thor- ough understanding of the dynamics of the involutional melan- choliac may be approached only through an understanding of the dynamics of this predisposing personality.

DESCRIPTION OF TIIE ANAL CI~IARACTER

The anal character has been described by many analytic au- thors.~, 4,1o The major traits ascribed to this character are orderli- ness, frugality, and obstinacy. Frugality is a continuation of t h e

656 INVOLUTIOI~AL MELANCttOLIA

anal habit of retention. Orderliness is an elaboration of the obedi- ence to, and the rebellion against the parental requirements cover- ing the regulation of the excretory functions. Tidiness, punctual- ity, meticulousness, propriety, all signify a displacement of the compliance to the parental requirements in regard to defecation. The sublimation of retentive attitudes leads to parsimony, miserli- ness, collecting, and hoarding. The reaction formation to expul- sive habits leads to cleanliness, orderliness, organization thorough- ness, efficiency, purity, and aversion to contamination and soiling. Sublimations of expulsive habits lead to extreme generosity, ex- travagance, painting, sculpture and so on.

Analytic authors generally agree that the anal character has its roots in the attitudes developed around the conflicts engendered by toilet training. Rigid attempts a t early toilet training are made by the parents--promising harshness and severity for disobedi- ence, and love and narcissistic gratification for obedience. The child, caught between his developing anal erotism and his need for love and narcissistic supplies from the parents, resolves this con- flict by the development of a forerunner of the super-ego, called by Ferenczi "sphincter morals," which is later replaced, when the introjected parental authority forms the super-ego?

In the development of the anal character--because of the rigid- ity of the super-ego's defenses against the instinctual anal needs --certain habitual defensive ego attitudes have been established. Upon the maintenance of these ego attitudes the integrity of the personality depends. The super-ego is now the source of self- esteem and narcissistic gratification formerly supplied by parental figures. I t will continue to supply these-narcissistic needs as tong as the individual continues to live up to its demands. It will with- draw narcissistic supplies when the personality fails to live up to its goals. Thus, the anal character's perception of failure to live up to the rigid goals of the super-ego would lead to a with- drawal of narcissistic supplies by the super-ego. Because of this constant threat, the anal character develops its characteristic rig- idity and compulsivity, as described in the foregoing. It is neces- sary to recognize that the compulsive behavior of the anal charac- ter is actually an attempt to accede to the demands of the super- ego . The compulsions are a defense whose aim is to ward off the threat of punishment by, and loss of narcissistic supplies from, the

JOSEPH BAR:NETT~ ARTHUR LEFFORD AND DONALD PUSt tMAlq 657

super-ego. To the anal character, compulsions are necessary to enable him to maintain self-esteem.

DECO~PI~NSATIOIq OF THE ANAL CHARAC~:~

In order to understand what leads to adaptive failure, considera- tion must be given ~o the specific compulsive behavior which has enabled the anal character to live up to his own super-ego demands. Such specific behavior patterns are as multitudinous as the diverse patterns of reaction seen in specific cases of involutional melan- cholia. I t is possible to consider compulsive defense behavior broadly with respect to adjustments to work, interpersonal rela-

-tionships, sexual adjustments, etc. In a given individual, there may be compulsive attitudes and needs with respect to any or all of these areas. Until the breakdown, the individual has been able successfully to live up to his super-ego's demands with respect to his needs in these areas. He has adapted at a specific compulsive level.

In the involutional period, readjustments become necessary. His character structure, however, demands that he act and behave in a manner no longer physically or socially possible for him. It is not the physiological or social changes p e r se that are crucial in the precipitation of the psychosis. I t is rather the unique and personal significance, for the compulsive character, of these changes that precipitates the breakdown. The economy of the compulsive char- acter is precarious. These changes imply his inability to continue his appeasement of the super-ego. Major environmental changes may occur to demonstrate to him his inability to continue his rigid adjustment. However, the unconscious perception of changes of a subtle nature may be the precipitating factor for the decompensa- tion. Should the ego at any time perceive or interpret some event as an inability toappease the super-ego, the anticipatory anxiety of loss of self-esteem occurs to detonate the cycle of depression.

Although the involutional period introduces specific traumata which are of grave danger to the anal character, it is expected that depressive states corresponding to the involutional agitated de- pression s will be seen in anal personalities before the physiologi- cal involution as well as long after it. Thus the descriptive term "involutional" is misleading insofar as it implies a causal relation- ship between the clinical syndrome and physiological involution.

658 INVOLUTIONAL MELANCHOLIA

PSYCHOPATHOLOGY OF THE AGITATED DEPRESSIONS

The dynamics of the agitated depressions show a marked similar- i ty to the typical dynamics of the reactive depressions. The dif- ferences in symptomatology reflect quite naturally the differences that do exist. The agitated depressions are superimposed on an anal character structure whose rcdson dYtre has become the ap- .peasement of a rigid, severe super-ego by compulsive character defenses. For this character type, narcissistic supplies are de- rived from the super-ego, but only as long as the defense mechan- isms of the ego continue in the policy of appeasement. When en- vironmental or physiological changes force the ego to perceive it- self as unsuccessful in its habitual defense reactions, anxiety in- tervenes, the ego mechanisms are paralyzed and further prevent fulfillment of compulsive needs, and the depressive cycle begins. The anticipated and feared loss occurs--the super-ego withdraws narcissistic supplies and the hostility inherent in the ambivalent relationship which the ego has with the super-ego is mobilized and directed against the super-ego. Further hostility is directed against the ego.

One sees here the essential dynamic differences between the re- active depression and the agitated depression of the involutional period. The reactive depressive feels a loss of love from an ob- ject in the environment; the involutional melancholiac, the with- drawal of love from within the personality. A reactive depressive, as has been seen, directs hostility against a currently incorporated object; the involutional melancholiac against an object incorpor- ated ifl early childhood. A trait of the anal character which leads to an important similarity in the dynamics is the ambivalence toward the super-ego. This ambivalence is reflected by the con- tradictory behavior so frequently seen in the compulsive charac- ter. I t is apparent that in the involutional melancholiac, the super- ego is an ambivalent object, much as is the external object of the reactive depressive.

In both types of depression, there is a loss of narcissistic supply ; in the agitated depression, from the super-ego; in the reactive de- pression, from the external object. Also, in both, depressionper.se is the result of hostility directed inwardly against two functions of the self, i. e., the ego and the super-ego. In the reactive depres- sions, hostility is directed against the currently incorporated ob- ject and against the ego, as the result of guilt over the expression

JOSEt'I-I BARI~ETT, ARTHUR LEFFORD AND DONALD PUSHIV[AN 659

of hostility. In the agitated depressions, hostility is also directed against the incorporated object, the super-ego, which represents objects incorporated in early life. However, a greater proportion is directed against the ego, as a result of (1) guilt arising from the ego's failure to accede to the super-ego's demands, and (2) guilt over the expression of hostility. Thus, in the agitated de- pression more self-directed hostility is directed against the ego. The ego is overwhelmed by guilty self-condemnation, which be- comes a more marked clinical feature in this type of depression.

Agitation, as an almost constant feature of this type of depres- sion, may similarly be explained on the basis of these dynamics. The personality of the anal individual is such that equilibrium can be maintained as long as the compulsive defense system satisfac- torily placates the super-ego. With the perception of failure, se- vere anticipatory anxiety occurs because of the certainty of loss of love and impending punishment by the super-ego. This anx- iety is present both as free-floating anxiety, and as attempts at motor release of anxiety. This inability to bind anxiety for later release is a further manifestation of the limitation and regression of the ego in one of its major functions.

This anticipatory anxiety also accounts for the frequently ex- pressed ideas of hopelessness and futility which appear in the agi- tated depressions. The overwhelming anxiety severely impairs ego functioning and, therefore, impairs attempts at adaptation. Thus the patient who states, "There is nothing that can be done, I am hopeless," is merely reporting his perception of his ego's in- capacity to do anything about the situation.

The refusal of food seen in severe depressions has been clari- fied by Gero. 3 Food represents gratification of narcissistic needs, as well as hunger, therefore symbolizing self-esteem. Anorexia signifies the denial of love and esteem in severe self-recrimination and is a form of self-punishment.

In conclusion, it is seen that the clinical symptomatology of the agitated depression reflects the dynamics of the personality. From this point of view, the agitated depressions may be considered as the decompensation of the anal character .

CASE PRESENTATIONS

Although the clinical symptomatology and the pre-psychotic anal personality of involutional melancholiacs have been noted and

660 INu MELANCHOLIA

presented by other writers, two cases will be briefly presented to emphasize these features and to correlate the apparent precipitat- ing factors with the dynamics of the personality. Both cases illus- trate the decompensation of anal personalities when confronted with the impossibility of maintaining their rigid work patterns.

Ca~e 1

G. J. was a 66-year-old male cabinetmaker, whose pre-psychotic personality was described as honest, sincere, truthful, thrifty, con- servative, pessimistic, proud, strong-willed, stubborn, and with a set of high moral standards. He was considered an excellent cab- inet maker--exacting, thorough, neat, punctual, impatient, rigid, and persistent in his work.

The onset of illness occurred about eight months prior to his mental hospital admission. At that time he had a heart attack for which he was hospitalized for two months. Following his return home and to work, he suffered another heart attack and was in- formed that he would be unable to resume his job. Almost imme- diately, he began to develop anxiety, lost his self-confidence, be- came seclusive, anorexic, and depressed. Agitation was a marked early feature. He was apathetic, expressed ideas of futility and hopelessness, stating that nothing could help him.

Case 2

M. C. was a 58-year-old married business man whose pre-psy- chotic personality was described as practical, parsimonious, over- demanding, domineering, persistent, obstinate, inconsiderate, un- appreciative, and given to severe temper outbursts. He complied to the strictest letter of Hebrew orthodoxy. Occasionally, he was given to episodes of compulsive generosity, during which he would seek out strangers, buy them meals and provide them with accom- modations. His hobby was modeling plastics.

During the two sears prior to his mental hospital admission, his business suffered numerous setbacks. He gradually became rest- less and anxious and worried constantly about his finances. He became progressively depressed and agitated, paced the floor wringing his hands. He expressed ideas of futility and hopeless- ness, and stated that he was a failure. He insisted that there were discrepancies in his early income tax returns and feared that the authorities were going to punish him.

ffOS:EPI-I BARNETT, ARTHUR LEFFORD AND DONALD I:~USI=IIVIAN 6 6 1

In both these cases, the anal pre-psychotic personality is unmis- takable. In the first case, the precipitating factors involved a phy- sical disability--two heart attacks--which precluded the mainte- nance of his rigid work adjustment. The patient showed anal char- acter traits of an essentially retentive type which embraced many facets of his personality. His most persistent and marked com- pulsive system, however, appeared to involve his work situation, which was just the system where re-adaptation along less compul- sive lines was indicated because of his heart attacks. Another in- teresting clinical observation is the appearance of impotence as a purely secondary symptom--apparently the result of withdrawal of libidinal cathexes seen so frequently in depression. In keeping with the dynamics, free-floating anxiety was seen to precede the early depressive elements. This is interpreted as anxiety over the impending loss of narcissistic supplies from the super-ego as a re- sult of the perception of, in this case, an environmentally-produced prohibition preventing maintenance of compulsive defenses.

I n the second case, one sees an anal character with an admixture of retentive and exputsive elements. An interesting example of ambivalence toward the super-ego is seen in a parsimonious, mi- serly individual who has outbursts of compulsive generosity. In this case, no physical precipitant is seen. Whether because of his own diminished productivity or because of economic conditions, he suffered business reverses. This was sufficient to demonstrate his inability to continue i n his anal attitudes toward money, at once retentive and expulsive, and this precipitated anxiety, followed by an agitated depression.

These two cases are presented primarily as illustrative material and can be supplemented by many cases seen by the authors and by many cases among those reported by others.

SummARY

1. The pre-psychotic personality of patients developing agi- tated depressions is described as the anal-compulsive character.

2. The development and characteristics of the anal character are outlined.

3. The agitated depressions are considered as the decompensa- tion of an anal character.

662 IlqVOLUTIONAL IViELANCHOLIA

4. The precipitating factors are considered to be traumata which prevent the maintenance Of characteristically rigid ego defenses.

5. A differential comparison is made of the psychodynamics of the reactive and agitated depressions.

6. The psychopathology of the symptoms is related to the pre- psychotic personality and its deeompensation,

7. Two illustrative cases are presented.

Syracuse Psychopathic Hospital Syracuse, N. Y.

REFERENCES

I. Freud 7 S. : Mourning and melancholia. In- Collected Papers~ Vo]. 4. Hogarth. London. ]925.

2. Abraha~n~ K. : Selected Papers. I-Ioga1~h. London. 1927.

3. Gero 7 G.: The construction of depression. Int . J . Psychoan, 17:4237 1936.

4. Fenichel, O. : The Psychoanalytic Theory of the Neuroses. Norton. New York. 1945.

5 . Jelliffe~ S. E , and White~ W. A. : Diseases of the Nervous System (Sth ed.). Lea and Febiger. Philadelphia. 1929.

6. Brew 7 M. F. : A study of precipitat ing factors in involutional melancholia. State IIosp. Quar t , 10:422, 192.5.

7. Titley, W. B. : Prepsychotie personality of involutional melancholia. Arch. Neurol. and Psychiat., 36:197 1936.

8. : Prepsychotie personali ty of patients with agi tated depression. Arch. Neurol. and Psychla t , 39:3337 1938.

9. Palmer 7 H. D , and Sherman~ S. H. : The involutional melancholia process. Arch. Neurol. and Psychlat., 40:762, 1931.

10. Jones, E. : Papers on Psychoanalysis. William Wood and Company. New York. 1928.